Endovascular Management of Unused Fenestrations or Branches in Fenestrated/ Branched Aortic Endograft

Learning Objectives: Endovascular management of unused fenestrations and branches in custom aortic endografts

Background: Fenestrated and branched aortic endografts (F/B EVAR) are now widely used as the main treatment option for a variety of aneurysmal aortic pathology from atherosclerotic degenerative aneurysm to chronic aortic dissection. The majority of these endografts are custom grafts where the F/B are designed according to the patient’s anatomy. In most cases, all the fenestration or branches are utilized during the procedure, connecting to the target arteries. However, in some clinical scenarios, not all the F/B are utilized. These include failed cannulation of target artery, interval occlusion of target artery during graft manufacturing, or in the case of the “off-the-shelf” devices; the target vessel is already occluded and hence the branch is no longer needed. Leaving these unused fenestrations or branches patent without occluding them will lead to an endoleak.

Clinical Findings/Procedure Details: Branch Device. There are several manufacturers of branch devices but for illustration purpose we are using Cook Medical t-Branch® device. For Cook Medical t-Branch®, there are two different side branch diameters, 8mm for the celiac and superior mesenteric artery (SMA) and 6mm for the renal arteries. These branches could be blocked by a variety of devices including: Amplatzer Vascular Plug, MVP microvascular plug (Medtronic), or extending the branch with a balloon expandable stentgraft followed by a vascular plug. 
Fenestrated Endograft. The majority of the fenestrations are 6 or 8mm in diameter. If there is sufficient length between the fenestrations, an aortic cuff could be placed covering the fenestration without interfering with other fenestration or branches. Patent Ductus Arteriosus (PDA) Amplatzer Duct Occluder or Amplatzer Muscular Ventricular Septal Defect (VSDs) are another alternative. Finally, deploying a balloon expandable stentgraft in the fenestration to increase the length for placement of a vascular plug/coil in the stentgraft. 
Limitations of each techniques would be illustrated in the presentations

Conclusion and/or Teaching Points: As Fenestrated and branch devices are used more frequently for the treatment of aortic aneurysms, interventionalists should be familiar with endovascular options for the management of unused fenestration or branches. This presentation illustrates the technical aspect and appropriate devices for occlusion of these unused branch/fenestration.